Inspection on 20/09/05 for Cedarfoss House

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedarfoss House 09/06/08

Cedarfoss House 14/06/07

Cedarfoss House 22/06/06

Cedarfoss House 14/10/04

Cedarfoss House 07/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Cedarfoss House 55 Hull Road Withernsea East Riding Of Yorks HU19 2EE Lead Inspector Sarah Sadler Unannounced Inspection 20th September 2005 09:30 Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cedarfoss House Address 55 Hull Road Withernsea East Riding Of Yorks HU19 2EE 01964 614942 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Willerfoss Homes Mrs Beverley Hutchesson Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Cedarfoss House is a privately run home situated in the seaside town of Withernsea on the East Yorkshire coast. Service users have access to a range of local shops, services, local transport and the sea front. The home is registered for sixteen adults aged 18 - 65 who have a learning disability. The accommodation is on two floors and consists of six single bedrooms and five double bedrooms. There are two lounges, a dining room and a conservatory for the clients to use. Clients using this service also have the benefit of a garden and patio area. The home does not have lift access to the upper floor therefore service users with a physical disability would be accommodated on the ground floor. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted eight and a half hours. Two inspectors Sarah Sadler and Angela Sizer undertook the inspection. Some of the service users were able to verbally communicate with the inspectors giving their views about the home and care offered. The manager was available throughout and two relatives and staff members were spoken with during this time. The outstanding requirements from the previous inspection were discussed, as were the findings of this inspection. This was completed approximately half way through the inspection and again at the end, with the manager discussing any areas requiring clarification. During the inspection the registered manager contacted the registered proprietor to express her dissatisfaction with the inspection. This is being dealt with jointly as a separate issue. The records of clients and staff were looked at along with a look at the bedrooms and communal areas within the home. What the service does well: What has improved since the last inspection? What they could do better: Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 6 Three small windows were broken and had not been made safe. An immediate requirement was issued to the home regarding this. Staffing levels do not meet the needs of service users. The hot water in the sink outlets is 67° centigrade and poses a risk to service users. Issues of allegations of potential abuse are not reported to the appropriate authorities. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection. EVIDENCE: Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Service users are assessed to ensure needs can be met. However this is not kept up to date which may prevent service users’ needs from being fully met. EVIDENCE: Service user files contain copies of the individual resident assessment form. This details the needs of these service users and how these needs are to be supported. Copies of Social Services review minutes are held in these files with no issues noted. Daily notes are kept of the support offered to service users and monthly summaries are also completed. These summaries are not always up to date, with one not being completed since May of this year. The registered manager reviews the service user files every twelve months to ensure that the contents remain up to date. Service users confirmed that “the care in the home is good, and staff are friendly”. Relatives confirmed that the service user has the freedom to go out into the local community as they choose. They also confirmed that their relative’s privacy and dignity is maintained. Service users do not hold keys to their room, which would enable them to maintain their own privacy and dignity. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,16,17 Not all service users are supported to fulfil their social needs. Service users are provided with a varied diet, but nutritional needs are not fully met. EVIDENCE: One service user attends the local adult education/day centre and also has a work placement. Four service users commented that they can “go out when they like”. The registered manager confirmed that two service users complete activities and that other service users complete very little activities and that this is due to either their choice or their level of learning disability. The registered manager confirmed that a psychologist had assessed a service user regarding activities, however this was not reflected in the psychologists report. Service user files included copies of a comprehensive risk assessment detailing different areas, enabling service users to undertake activities. For example one service user accesses their local community independently and records of when this occurs and the instructions that staff have followed are clearly recorded. The relatives confirmed that their relative attends a social club and day centre. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 11 Service users confirmed that they “like the food”. The food was well presented and service users were offered support in the eating of their meal. Choices regarding food are offered to service users on a daily basis, with the menu on the day of the inspection being either pork casserole or fish fingers. Fresh vegetables were available and there were good portion sizes. One service users’ weight is regularly monitored, this service user has lost weight over recent months, however no evidence was available at the inspection that this had been investigated. This was discussed further with the management and it was confirmed that this work had been undertaken and evidence was provided of this work for another service user. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Service users are supported with physical health needs but emotional needs are not always met. EVIDENCE: Service user files included details of different professionals who support service users, for example, the Community Nurse Learning Disabilities, optician and the chiropodist. One service user has required additional health support at night and a nursing style bed has been purchased by the home to assist with this. Staff were observed to speak appropriately to service users, asking them if they required support in maintaining personal hygiene and offering this support. A relative confirmed that, “ they feel their relatives welfare is looked after, their relative has visited the GP and a dentist is being arranged”. Additional records required to support service users with specific individual needs are kept within service user files. Some service users require 1:1 support throughout the day, one of these service users were observed to spend time relaxing in the home, with staff Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 13 checking on these service users approximately every ten minutes. The other service user was not observed to receive 1:1 support. One service users’ file reflected that the 1:1 support should be available to complete activities throughout the day, this did not occur. However the registered manager details that this is no longer the case and that the care plan is to be updated. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People are able to complain. Service users are not fully protected from abuse. EVIDENCE: There is a complaints policy held within the home, which details the actions to be taken should a complaint be made. The policy does not include the contact details of the CSCI. Relatives confirmed that they were not aware of the complaints procedure but would know what to do if they wished to complain. There is a copy of the local authorities policy ‘The Protection of Vulnerable Adults’ available within the home. However none of the staff are aware of this procedure and no evidence of training with this was found. One service users’ notes reflected that a service user had made allegations about inappropriate staff actions; this had not been reported by the registered manager under the POVA guidelines. There is not evidence that all staff have undertaken a Criminal records bureau check prior to employment. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Service users are able to personalise their home and have communal areas, the works required detract from the homeliness and safety of the home. EVIDENCE: The two lounges of the home were found to be comfortable. A service user recently requested a new sofa in the lounge and this is in place. Service users are able to personalise their rooms, with individual lockable storage space. There are screens available in shared rooms that assist in the maintaining of service users’ privacy. There are sinks in service users’ rooms and the registered manager confirmed that the service users purchase some individual toiletries with the home purchasing shared toiletries. There is a staff call system throughout the home, with staff responding appropriately to this. An old style nursing bed that allows the headboard to be adjusted so that the service user may rest in different positions has recently been purchased. It is however in need of some maintenance as it is rusty. Curtains are in place throughout the home, however many of these had curtain hooks missing and the registered manager agreed required attention. The Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 16 registered manager confirmed that this was due to the behaviours of one service user. There are communal toilets available within the home, however soap and towels are not available in these. The registered manager stated that this was due to another service users’ needs. There are two bathrooms available to service users and the downstairs bathroom also has a shower facility. The hot water in the downstairs bathroom was close to 43° centigrade, however the hot water in the upstairs bathroom and toilet were found to be cold. The landing area of the home had a strong smell of urine and the registered manager confirmed that this carpet was due for cleaning. The registered manager advised the inspectors that there is currently a vacancy for a cleaner within the home and consequently there are cobwebs in some areas. The registered manager informed the inspectors that after inspecting a service users’ room and bedding they should wash their hands, as this bedding was not clean. Service user rooms have star key in place which ensure that rooms can be locked from the outside, however they do not offer the service user the option of being able to lock the room themselves when they are in the room to ensure privacy. This was discussed at length with the registered manager, who stated that currently there are no service users in the home who would benefit from a change of locks; the use of risk assessments to identify this was further discussed. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Adequate staff numbers do not support service users. Staff have not been correctly recruited and appropriately trained. EVIDENCE: The duty rota provided reflected that there are 445 hours per week provided to support service users. The registered manager detailed that 2 service users receive 1:1 staffing for 12 hours a day, 7 days a week and that another service user receives 1:1 staffing for 2 hours a day, 7 days a week. These hours total 192 per week, leaving 253 hours for all basic care. Which means the additional staffing hours are being used to support other service users. One of the three staff files examined included details of a criminal records bureau (CRB) check. The registered manager confirmed that one staff member had received a Protection of Vulnerable Adults (POVA) first check and was awaiting their full CRB check. However the home was not following Department of Health guidance regarding the supervision of this staff member. Evidence that references had been undertaken on staff or identification of staff was not available. The registered manager stated that many of the staff files do not contain all of the required information and that these staff were employed prior to her being the registered manager for the home. Two supervisions have been undertaken for two of the staff members this year. The third staff member has recently commenced employment in the home and has received one supervision. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 18 Staff training reflected that two of the three staff on duty had undertaken very little training with one of the staff having undertaken no training and the other staff member having undertaken fire training only. Staff detailed that they are undertaken moving and handling with service users. Staff were not aware of the Protection of Vulnerable Adults (POVA) polices or procedures. There is an induction pack held within the home, however there was no evidence that this meets the requirements of Skills 4 Care. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,41,42 The record keeping systems in the home do not safeguard service users’ rights. Service users’ Health and Safety is not always safeguarded. EVIDENCE: Communal daily handover notes are kept within a diary in the home. The necessity for individual records to be kept in relating to data protection was discussed with the registered manager, who was advised to seek further advice regarding this. A member of staff was identified in the communal records as having being suspended on questioning the registered manager stated that this was due to the member of staff not following the correct sickness reporting procedures. Bath temperature records are kept that reflect that daily checks of the bath temperatures are undertaken. The registered manager confirmed that the requirements from the last environmental health officer visit have been met. Portable appliance (PAT) testing is undertaken and documents are in place to confirm the maintenance of the gas and main electrical wiring systems in the Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 20 home. The hoist has been serviced and emergency lights are regularly checked. Some hot water outlets tested at sinks, both in service user individual rooms and communal areas was found to be around 67 °centigrade, the registered manager confirmed that all hot water outlets at sinks are approximately 67° centigrade. The registered manager also confirmed that this had been the case for over one year and was to be addressed as part of the ongoing maintenance within the home. Several taps did not have the correct colour on the top to distinguish whether they supplied hot or cold water. Service users individual risk assessments identify that service users are at risk from hot water and that a care plan has been implemented for this. The care plan describes the support to be given to ensure a service users takes a bath safely, but does not describe how service users are supported to prevent the risk of scalding from the hot taps in the home. The downstairs toilet window had glass missing and the registered manager informed the inspector that two windows in the dining area of the home had glass missing. These had sharp areas noted that may cause a risk to service users. The external exit door in the dining room had broken glass that had been taped up; this may also cause a risk to the safety of service users. An immediate requirement was issued to the home regarding this. Window restrictors are not in place and it is recommended that a risk assessment be completed regarding this. The registered manager confirmed that the home has a clinical waste agreement that ensures that the disposal of clinical waste meets the latest legislation. The registered manager is to forward a copy of this agreement to the CSCI. The use of door wedges has ceased and a fire officer has inspected the home in May of this year. There are monthly fire drill records, with the last drill being completed in May 2005. The registered manager confirmed that the front exit door is a fire door and has a specialised lock in situ to ensure the door opens when the fire alarm is activated. There is also a deadbolt on the base of the door and it is recommended that this be removed. Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 1 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score x 1 X 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cedarfoss House Score 1 1 X X Standard No 37 38 39 40 41 42 43 Score 1 X X X 1 1 X DS0000019658.V251267.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA12 Regulation 16 (2(m, n)) 18 Requirement The registered person must ensure that all service users have the opportunities to participate in fulfilling activities. The registered person must ensure that service users’ needs are met through appropriate staffing levels. The registered person must ensure that service user records are kept up to date. The registered person must ensure that the complaints procedure includes the contact details of the CSCI. The registered person must ensure that service users are protected by the homes procedures for the reporting of allegations of abuse. The registered person must ensure that all staff are aware of the correct procedures for the handling of allegations of abuse. The registered person must ensure that the home is kept in a good state of repair internally; curtains should be hung correctly and equipment should not be rusty. DS0000019658.V251267.R01.S.doc Timescale for action 20/10/05 30/09/05 2 YA18YA33 3 4 YA19 YA22 17 22 30/09/05 20/10/05 5 YA23 13,21 30/09/05 6 YA23 13,21, 18 30/09/05 7 YA24 23 (2) 30/10/05 Cedarfoss House Version 5.0 Page 23 8 9 YA30 YA30 16(2(k)) 23 (j) 10 11 YA30 YA30 16 13 (3) 12 YA30 13(3) 23(2(a)) 13 YA32YA34 19, schedule 2 14 YA35 18 15 16 YA36 YA37YA42 18 23 (2(p)) 17 YA37YA42 13 (4). 23(2) The registered person must ensure that the home is kept free of offensive odours. The registered person must ensure the provision of bathrooms with hot and cold water. The registered person must ensure that service users are provided with clean bedding. The registered person shall provide a copy of the agreement that ensures the appropriate handling of clinical waste. The registered person must ensure the provision of appropriate hand wash facilities to prevent the spread of infection. The registered person must ensure that recruitment practices include that references and CRB checks are undertaken for all staff. When staff start work with a POVA first check only, the Department of Health Guidelines must be followed with the person supervised at all times. The registered person must ensure that staff are inducted and trained to ensure meeting the health, safety and support needs of the service users. The registered person must ensure that the staff team are appropriately supervised. The registered person must assess the risk of the unregulated water temperature of the hand washbasins in service users’ bedrooms. Control measures must be put in place to reduce identified risk. This is an ongoing requirement with a previous compliance date of10.06.05. The registered person must ensure that glass and windows DS0000019658.V251267.R01.S.doc 30/10/05 30/10/05 30/09/05 30/10/05 30/10/05 30/09/05 30/09/05 30/10/05 10/06/05 21/09/05 Page 24 Cedarfoss House Version 5.0 are safe. 18 19 YA37YA42 YA37YA42 23 (4) 13 (4(c)) The registered person must ensure that fire drills take place regularly. The registered person must ensure that risk assessments are in place for the unguarded radiators with high surface temperatures and control measures put in place. This is an ongoing requiremnent with a previous compliance date of 10.06.05. The registered person must ensure that fire doors have the correct locking devices to assure adequate means of escape in the event of a fire or other emergency. 30/10/05 10/06/05 20 YA37YA42 23(4) 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA17 YA24 YA32 Good Practice Recommendations The registered person should ensure that all care reviews are up to date. The registered person should ensure that individual service users’ records reflect any actions taken regarding weight. Suitable locks should be provided to service users’ rooms unless a risk assessment identifies otherwise. Consideration should be given to encouraging staff to undertake the Learning Disability Award Framework training as refresher for experienced staff or as underpinning knowledge for NVQ training. 50 of staff should hold an NVQ qualification by the end of 2005 The registered person should ensure that records are individual – maintaining the service users’ rights. A risk assessment should be in place regarding the provision of window restrictors. 5 6 YA41 YA42 Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedarfoss House DS0000019658.V251267.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!